We congratulate Schloesser and co-workers on their insightful cohort study assessing the prevalence, perception and role of panic in episodic breathlessness (1). They show elegantly that breathlessness episodes mostly have a duration of under 10 minutes [median: 7.0; standard deviation (SD): 2.1] but those sufferers rate their impairment due to the episodes as high [8.3 on numerical rating scale (NRS) 10 with SD of 1.5 (NRS: 0= no impairment at all, 10= worst imaginable impairment)]. Notably, only 2% of patients reported not having panic during the episode whereas 35% suffered from panic disorder or panic syndrome. Experiencing panic outside the breathlessness episodes correlated significantly with panic intensity during breathlessness episodes (r=0.527, P≤0.001). Their primary study (2), which took the form of a longitudinal observational cohort study revealed that cognitive behavioural therapy (CBT) improved symptomatic status and quality of life which led to their conclusions that this could be a useful adjunct to other treatments in a palliative care setting.
Yet not all patients nor centres have CBT available to them. And based upon the surprising recent data on opiates in heart failure, we should approach tailored care for symptoms in people with a variety of incurable diseases in the same way that we would for any other setting, namely based upon data from randomised controlled studies carried out in a pathway of care informed by observational data. Perhaps rather than targeting the symptoms themselves, we should also consider targeting the anxiety that contributes and exacerbates them. Whether this should be with a medical or non-medical intervention or a combination of both requires further study.
For example, one potential agent could be pregabalin, a potent anxiolytic widely used and highly effective against panic disorder in patients with short and frequent breathlessness episodes. Although published data are limited, we have experience of it is potential in both cancer and non-cancerous conditions such as chronic airways disease, heart failure and pulmonary hypertension. It is particularly effective when there is a large overlay of anxiety.
We propose that future studies should include both objective and subjective endpoints and must be large enough to help determine which intervention (or combination of interventions) is best for which setting. The work by Schloesser provides a solid foundation for including CBT as one of the interventions that require testing, but if we are to help our future patients, it is time to cast the net wide and to do so within a pathway of care that includes multiple potential targets to improve quality of life. To our knowledge this is the first mention of pregabalin for the treatment of anxiety in the context of episodic breathlessness in patients with chronic incurable disease.
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Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://apm.amegroups.com/article/view/10.21037/apm-23-547/coif). J.G. serves as an unpaid Associate Editor of Annals of Palliative Medicine from February 2022 to January 2024. The other author has no conflicts of interest to declare.
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- Schloesser K, Bergmann A, Eisenmann Y, et al. Interaction of panic and episodic breathlessness among patients with life-limiting diseases: a cross-sectional study. Ann Palliat Med 2023;12:900-11. [Crossref] [PubMed]
- Schloesser K, Bergmann A, Eisenmann Y, et al. Only I Know Now, of Course, How to Deal With it, or Better to Deal With it: A Mixed Methods Phase II Study of a Cognitive and Behavioral Intervention for the Management of Episodic Breathlessness. J Pain Symptom Manage 2022;63:758-68. [Crossref] [PubMed]